Complaints about the treatment and care of a dying man while he was a patient at Bannockburn Hospital have been upheld by the Ombudsman.

The son of the patient, referred to as Mr A, raised eight complaints about the care and treatment given to his father in the final days of his life, two of which were supported by the investigation.

The elderly man had been living in a residential home.

After admission to Stirling Royal Infirmary for, amongst other things, acute renal failure, he was transferred to Bannockburn Hospital in November 2010 for rehabilitation.

At the time, he also had a urinary tract infection and a tracheostomy (for laryngeal cancer). He died in SRI on December 28, having been transferred there the previous day.

The ombudsman upheld a complaint that two out-of-hours (OOH) doctors who separately attended Mr A at Bannockburn assessed and treated him inappropriately, in particular failing to recognise his poor condition and arranging for a transfer to SRI. A complaint that the decision making, care and communication of nursing staff at Bannockburn in relation to provision of palliative care for Mr A was inappropriate was also upheld.

On the first, the Ombudsman concluded: “I am of the view Mr A should have been transferred to SRI. At the time of initial deterioriation, discussions should have taken place with either Mr A or his son about this. If the board have not conducted a critical incident review regarding this situation, they should do so now.

“Further, I recommend the board consider the practicality of having routine discussions regarding care escalation for patients admitted to Bannockburn Hospital and other similar units; the means by which it can be ensured that severe illness is promptly recognised in such units by use of a scoring system; and a strategy for determing as soon as a patient in Bannockburn or similar unit becomes acutely unwell, and where there has been no anticipatory care discussion, the appropriate limits of care.”

On the second he said: “From available medical notes I am satisfied that on December 27, 2010, nursing staff contacted an OOH doctor at 8.16am and he attended at 9.15am. About this time nursing staff also phoned Mr A’s son. Thereafter, despite Mr A’s condition which was deterioriating with a sudden decline at 7.20pm, no further call was made to an OOH doctor until 8.46pm, which was at the request of Mr A’s family.

“The situation with regard to Mr A’s resuscitation status was also confused and there was little documentary evidence concerning it or about any conversations which should have taken place between staff and Mr A and/or his family. I recommend the board emphasise to staff in Bannockburn Hospital the importance of keeping full and proper records, including notes of conversations and phone calls, also the board remind hospital staff of the ‘Do Not Attempt Cardiopulmonary Resuscitation Policy’ and provide evidence they have done so.”